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Trauma Flashcards

1
Q

We are the liver and spleen so susceptible to injury via blunt forces? (3)

A
  1. Heavy and relatively free to move which leads to tearing
  2. Soft so when starts bleeding it is propagated
  3. Very vascular
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2
Q

How much of traumatic pelvic bleeding is venous?

A

Around 80%

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3
Q

What is the mortality of an open pelvic fracture?

A

50%

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4
Q

Which patients does the FPHC consensus statement suggest may not need a binder? (5)

A
  1. Mechanism not suggestive of pelvic injury and
  2. Haemodynamically stable (HR<100, SBP >90)
  3. GCS >13
  4. no distracting injury
  5. no pain in pelvis
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5
Q

What does FPHC consensus statement say about type of pelvic binder used? (2)

A
  1. No good evidence for one device over another
  2. Best evidence currently is for SAM Splint or T-POD device
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6
Q

What is the FPHC consensus statement with regards to femoral fractures and suspected unstable pelvic fractures and haemodynamically unstable patients?

A
  • if traction of legs will delay transfer +/- worsen instability of patient (via pelvic disruption), they should be pulled to length and then tied together at knees and a figure of 8 around ankle
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7
Q

What does JRCALC recommend with regards to transporting the distal part of of an amputation? (4)

A
  1. Remove any gross contamination
  2. Cover the part with a moist dressing
  3. Secure in plastic bag
  4. place bag in a container with ice
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8
Q

What are the protective layers of the skull from outer layer inwards

A
  1. Skull
  2. Dura mater
  3. Arachnoid mater
  4. Pia mater
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9
Q

What is the Monro-Kellie Doctrine?

A

The sum of the volumes of brain/CSF/blood is constant. A rise in 1 will therefore precipitate a drop in 1 or both of the others.

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10
Q

What 2 syndromes are associated with hyperacute head injury?

A
  1. Neuroventilatory syndrome
  2. Neuro-cardiac syndrome
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11
Q

What is neuroventilatory syndrome?

A

Impact brain apnoea

Concussive force to Pre-Botzinger complex of medulla oblongata

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12
Q

What is neurocardiac syndrome?

A
  • Cardiogenic failure secondary to locally released noradrenaline from myocardial sympathetic nerve terminals leading to neurogenic stunned myocardium.
  • creates reverse-Takusubo picture (intact apical contraction/ impaired heart base contracticility)
  • pump failure may decrease further secondary to systemic cathecolamine induced afterload +/- impact brain apnoea
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13
Q

How is cerebral perfusion pressure calculated?

A

CPP = MAP - ICP

assume ICP >20cmH20 so aim MAP >80 mmHg

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14
Q

How much % decrease in effect does each 20mins delay in TXA cause?

A

10%

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15
Q

At what GCS does nice recommend giving TXA?

A

12 or less

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16
Q

What does JRCALC states about anti-platelet tx nd HI?

A

Should be conveyed unless aspirin monotherapy

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17
Q

What does JRCALC recommend for agitated head injuries?

A

Cautious use of midazolam

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18
Q
A
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19
Q

What are the indications for immediate CTH in children? (8)

A
  1. ? NAI
  2. Seizure
  3. GCS <14 at presentation
  4. GCS <15 at 2 hours
  5. ? skull # / tense fontanelle
  6. Basal skull # signs
  7. Focal neurological deficit
  8. Bruising/swelling >5cm in <1years
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20
Q

What are the risk factors that may require observation in paeds head injurys? (5)

A
  1. LOC >5mins
  2. Amnesia > 5 mins
  3. Abnormal drowsiness
  4. 3 or more vomits
  5. Dangerous MOI
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21
Q

If a child has one risk factor following head injury what should be their management?

A

4 hours observation

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22
Q

If a child has more than one risk factor following head injury what should be done?

A

CTH < 1hour

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23
Q

What are the increased risk factors needing imagine in the Canadian c-spine rules? (3)

A
  1. Over 65years
  2. Dangerous MOI
  3. Parasthesia in the extremities
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24
Q

What constitutes a dangerous MOI in the Canadian C-spine rules? (5)

A
  1. Fall over 3 foot or 5 stairs
  2. Axial load to head
  3. High speed MVC (>100kmph)/rollover/ejection
  4. Motorised recreational vehicles
  5. Bicycle collision
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25
Q

What are the low risk factors in the Canadian C-Spine rules? (5)

A
  1. Simple rear end shunt
  2. Sitting position in ED
  3. Walking at any point
  4. Delayed onset neck pain
  5. Absence of midline tenderness
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26
Q

How many low risk factors do you need to avoid imaging in the Canadian C-spine rules?

A

1

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27
Q

What is the final step in the Canadian C-Spine rules?

A

Can they rotate their neck 45 degrees left to right

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28
Q

What are the indications for immediate CTH in adults? (7)

A
  1. GCS <13
  2. GCS <15 after 2 hours
  3. Open/suspected skull #
  4. Signs basal skill #
  5. Seizure
  6. Focal neurology
  7. More than 1 vomit
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29
Q

Within what period should patients on anticoagulation have a CTH according to NICE?

A

8 hours

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30
Q

If an adult patient has no indication for CTH immediately and is not on anticoagulation, what is the next question to be asked?

A

Any LOC or amnesia - if no then no imaging
If yes move onto risk factors

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31
Q

What are the risk factors used to determine whether an adult patient needs a CTH within 8 hours who have had a LOC or amnesia? (4)

A
  1. Over 65years
  2. Hx bleeding/clotting disorder
  3. Dangerous MOI
  4. > 30mins retrograde amnesia (events before injury)
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32
Q

Describes the myotomes in the upper limb (6)

A

C5 - deltoid
C5/6 - biceps jerk
C6 - wrist extensors
C7 - elbow extensor/triceps jerk
C8 - finger flexors
T1 - little finger abductors

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33
Q

Describe the lower limb myotomes (5)

A

L2 - hip flexors
L4 - knee extensors
L5 - ankle dorseflexors
S1 - ankle plantar flexors
S5 - anal reflex

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34
Q

What dermatome is the thumb?

A

C6

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35
Q

Where is the dermatone C7?

A

Middle finger

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36
Q

What dermatone is the little finger?

A

C8

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37
Q

What dermatone is the:
1. nipple
2. xyphoid process
3. Umbilicus

A
  1. T4
  2. T6
  3. T10
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38
Q

Describe the dermatomes of the lower limbs (4)

A
  1. L3 = medial knee
  2. L4 = lateral knee
  3. L5 = dorsum foot + 1st-3rd toes
  4. S1 = lateral malleolus
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39
Q

What spinal levels to the sympathetic fibres extend from?

A

T1 - L3

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40
Q

What spinal levels do the parasympathetic fibres extend from?

A

S2-4

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41
Q

At what spinal level can a SCI lead to neurogenic shock?

A

T6 or above

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42
Q

What causes neurogenic shock?

A

Loss of sympathetic autonomic outflow

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43
Q

What neurology is associated with central cord syndrome?

A

Arms weaker than legs

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44
Q

What neurology is associated with anterior cord syndrome? (4)

A
  1. Complete motor loss below lesion
  2. Loss of pain/temp below lession
  3. Preserved sensation/vibration
  4. Autonomic dysfunction
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45
Q

What neurology is associated with Brown-Sequard syndrome?

A
  1. Weakness/paralysis on 1 side
  2. Loss on sensation on the other
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46
Q

What is the mechanism for acid burns?

A

Coagulative necrosis

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47
Q

What is the mechanism for alkali burns?

A

Liquefactive necrosis

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48
Q

What are alkali burns worse than acid?

A

Acid burns form a barrier which prevents deep penetration into the skin, alkalis cause liquefactive necrosis which means it can penetrate deeper into the skin

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49
Q

What is are the voltage cut off of:
- low voltage
- high voltage

A
  1. <1000V
  2. > 1000V
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50
Q

What type of current is normal low voltage and can it lead to?

A
  1. AC domestic current
  2. Arrhythmia
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51
Q

What does high voltage electricity normally cause? (3)

A
  1. Full thickness burns at both entry and exit sites (internal damage can be far worse than appears externally)
    - Tissue damage secondary to heat generated by resistance of tissues
  2. Muscle spasms/secondary trauma from being thrown causing bony/SCI
  3. Arrhythmia particularly if chest involved
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52
Q

What type of tissue leads to the most damage when conducting high voltage electricity and why?

A

Bone because it has the highest resistance, it is the resistance that causes heat and bone can therefore become very hot and lead to further damage once the current has stopped.

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53
Q

What surgical interventions might be require of high voltage burns?

A
  • may need aggressive surgical intervention inc. fasciotomy and amputation
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54
Q

What can muscle damage related to high voltage burns lead to?

A

Myonecrosis, compartment syndrome and rhabdo with renal failure

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55
Q

What does a lightening strike lead to and what might be a protective factor?

A

Death unless it has already passed throught another object

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56
Q

Describe the palm method of assessing burns size and in what are the weakness of using it

A
  1. Palm INC. adducted fingers = around 1% TBSA (patients hand, not clinicians)
  2. Some debate as to the accuracy, particularly in small kids and obese patients
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57
Q

What burns assessment does the FPHC consensus statement recommend? (2)

A
  1. Lund and Browder chart
  2. Mersey burns app (or similar)
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58
Q

Describe superfical burns?

A

Erythema only,not included in burns calculation

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59
Q

What differentiates superficial burns from superficial dermal/superficial partial?

A

Blisters - fluid lifts dead epidermis off dermis

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60
Q

What is the difference between deep dermal/ partial and superficial dermal/partial? (3)

A

Extends into dermis

  1. Decreased sensation secondary to damage to nerve endings
  2. Hallmaark = increase CRT due to damage of dermal vascular plexus
  3. Can be ‘blotchy’ pink/red colour secondary to extravasation of the Hb from damaged vessels
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61
Q

Describe full thickness burns

A

Can include fat/fascia/muscle/bone

  • ‘charred’ or ‘leathery’
  • ‘woody’ feel
  • insensitive (but surrounding non full thickness burns with be painful)
  • non blanching
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62
Q

What questions should be asked to any burns patient? (4)

A
  1. Were they trapped and if so for how long?
  2. Did clothes catch fire?
  3. Any cooling?
  4. Any explosion/ were they thrown?
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63
Q

What level of CO is classed as severe?

A

> 30%

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64
Q

Why does CO lead to hypoxia?

A

CO x 240 more affinitity to Hb than oxygen which shifts 02 dissociation curve to the left

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65
Q

What will pulse oximetry be like with CO poisoning and why?

A

Normal as unable to differentiate between carboxyhaemoglobin and haemoglobin

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66
Q

What is a normal value of COHB in:
1. non-smokers
2. smokers
3. heavy smokers

A
  1. < 3%
  2. <5%
  3. <9%
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67
Q

What is the treatment (initially) for CO poisoning and why does it help?

A

High flow oxygen because it reduces the half life of COHb from 320mins to 80mins

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68
Q

What is the mechanism of cyanide poisoning?

A

Usually from burning plastic

Poisons mitochondria and prevents further cellular oyxgen use leading to anaerobic metabolism

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69
Q

What are 2 treatments available for cyanide poisoning?

A
  1. Hydroxycobalamin (Cyanokit)
  2. Dicobalt edetate (Kelocyanor)
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70
Q

To what depth should an escharotomy incision be?

A

Down to unburnt skin

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71
Q

What 3 lines should be made in a breast plate escharotomy?

A
  1. Mid clavicular to ant axillary line to costal margin bilaterally
  2. Transverse subcostal
  3. Transverse infraclavicular
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72
Q

What are the % burn NICE in hospital thresholds for:
1. Adults
2. Kids
3. < 18months old

A
  1. 15%
  2. 10%
  3. 8 %
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73
Q

What is the Parkland formula?

A

4 x wt (kg) x TBSA
3 x wt (kg) x TBSA (kids)

First half in initial 8 hours
Second half in following 16 hours

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74
Q

What does JRCALC recommend for burns fluid resusitation?

A

1L warmed fluids / hr (adult)
10ml/kg/hr paeds

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75
Q

What should the first steps be in with chemical burns?

A

Remove agent, removed contaminated clothes and if liquid, irrigate well

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76
Q

What is the recommended to use in decontaminating both acids and alkalis?

A

Diphoterine (normalises PH more quickly)

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77
Q

If Diphoterine is not available, what fluids should be use to decontaminate acids/alkalis?

A

Isotonic or hypertonic fluid because water can propagate chemical deeper into the skin

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78
Q

How long should chemical burns be irrigated for?

A
  • until pain improved which is a useful crude sign that PH has improved
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79
Q

How does hydrofluric acid lead to burns?

A
  • H+ ions dissociate on contact with skin and lead to liquefactive necrosis allowing acid to penetrate deeply
  • Free flouride ions bind to calcium and magnesium ions leading to systemic hypomagnesia and hypocalcaemia
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80
Q

How should hydrofluric acid be treated? (4)

A
  1. Irrigate
  2. Calcium gluconate gel
  3. IV/intra-arterial calcium if extreme
  4. Specific agent = hexaflourine
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81
Q

What is the specific agent for hydrofluric acid tx?

A

Hexaflourine

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82
Q

How should tar/bitumen burns be treated?

A
  • they are heated to around 150 degrees and cause full thickness burns
  • cool with water to solidify and then remove with toluene or peanut/paraffin oil
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83
Q

How does the FPHC consensus statement divide airways burns? (2)

A
  1. Supraglottic (nose/oropharynx and larynx) - most common
  2. Infraglottic
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84
Q

How can infraglottic burns be caused? (5)

A

Steam inhalation
Aspiration of scalding liquid
Blast injury
Flammable gas under pressure
Aerosolised chemicals

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85
Q

What are the features of infraglottic burns? (5)

A
  1. Impaired ciliary activity
  2. Hypersecretion
  3. Oedema
  4. Mucosal ulceration
  5. Bronchial spasm
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86
Q

What 3 considerations should be made with intubation in patients with airway burns?

A
  1. Largest size tube that will be placed (bronchoscopy on ITU)
  2. Uncut (airway will swell)
  3. Careful with tube tie
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87
Q

What features have been shown to correlate with need for RSI (FPHC)? (6)

A
  1. Full thickness facial burns
  2. Stridor
  3. Resp distress
  4. Swelling on larygnoscopy
  5. Smoke inhalation
  6. Singed nasal hairs
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88
Q

When does FPHC recommend using cyanide antidote?

A

Suspected smoke inhalation AND:
- altered mental status
- CV instability

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89
Q

What 3 categories of burns severity does FPHC recommend using pre-hospital?

A

< 20%
20-50%
> 50 %

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90
Q

What does FPHC say about water cooling of thermal burns? (3)

A
  1. Water < 20 degrees (12 ideal)
  2. 20 mins
  3. Not ice water secondary to risk of tissue necrosis
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91
Q

What does FPHC recommend with regards to first aid for chemical burns? (3)

A

1.Treat any chemical burn ASAP regardless of delay to presentation

  1. Use amphoteric solution as first line
  2. Irrigate for as long as possible
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92
Q

When does FPHC state fluid resus should be commenced pre-hospital in:-
- adults
- paeds

A

> 20%

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93
Q

Describe the FPHC ‘threshold’ method for estimating pre-hospital fluid resusitation?

A
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94
Q

What analgesia should be avoided in burns?

A

NSAIDs if requiring fluid resus

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95
Q

When does FPHC recommend chest escharatotomy?

A

Circumferential or near circumferential eschar with imprending or established respiratory compromise to to thoraco-abdominal burns

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96
Q

What is the definition of crush injury?

A

Direct injury to a body part which has undergone a prolonged static compressive force sufficient to interfere with normal tissue metabolic function

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97
Q

What is the definition of crush syndrome?

A

Systemic consequences of muscle + soft tissue trauma

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98
Q

What 3 factors make crush syndrome more likely?

A
  1. Increased compressive force
  2. Increased muscle bulk
  3. Increased time
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99
Q

Describe rescue cardioplegia

A

Occurs on release of compressing force

  • cold ‘toxic’ blood released back into systemic circulation leading to a sudden and transient increased preload. Causes atrial stretch which can lead to asystole of AF
  • Simultaneous rapid drop in afterload + SVR as blood moves back into affected limb
  • both lead to acute hypotension when limb released
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100
Q

What can make the affects of rescue cardioplegia worse?

A
  • blood released ‘ideal cardioplegic solution’ leading to arrhythmia
  • cold/hyptertonic/acidotic/ raised k+/ca2+/Mg2+/P04D
101
Q

Describe the pathophysiology of crush syndrome

A
  • Constant external mechanical force prevents cell wall integrity by forcing extracellular cations + fluid against normal electrochemical + osmotic gradient into cells
  • cell wall extrusion pumps become overhwhelmed allowing water with dissociated Na+/Cl-/Ca2+ into cell
  • ultimately leads to death
102
Q

When is irreversible cell death caused by crush syndrome?

A

<1 hour but no universally accepted ‘safe time’

103
Q

What is compartment syndrome?

A

Intramuscular compartment forces act continualy above DBP leading to comrpession and death of nerves/blood vessels/muscle

104
Q

Describe the pathophysiology of compartment syndrome

A

Integrity of muscle cell wall breached and intracellular components move extracellular and into damaged tissue

Cell content forced into vascular compartment lead to systemic affects

105
Q

How are kidneys damaged in compartment syndrome? (2)

A
  1. Direct damage of intracellular substances (proteases/purines)
  2. Indirect - attempt to filter acidotic plasma + myoglobin damage
106
Q

How does myoglobin damage kidney?

A
  • Myoglobin itself not nephrotoxic but when systemic acidosis lead to pH urine< 5.6 myoglobin converted to larger protein Ferrihaemate.
  • This is directly nephrotoxic and causes mechanical obstruction of nephron lumen
  • hypovolaemia and third space shift makes this worse
107
Q

What is the protein that myoglobin becomes when urine PH < 5.6

A

Ferrihaemate

108
Q

How should suspended patients be rescued?

A

ASAP and placed horizontally

109
Q

What has been shown to improved outcomes in trapped earthquake patients?

A

Systemic resus with sodium and potassium containing fluids (20ml/kg - 10ml/kg elderly)

110
Q

Describe the pain response in crush injury

A

Initially reduced due to endorphins and pressure neuropraxia but this will increase as limbs swell and endorphins wear off

111
Q

When should alkaline diuresis be considered in crush injury?

A

If evacuation time >4 hours

112
Q

How is alkaline diuresis performed?

A
  1. 50ml 8.4% soidum bicarbonate to each alternate 1L fluid
  2. If prolonged transfer alternate 5% dex to prevent sodium overload
  3. Aim urine PH >6.5

Really should be done in hospital

113
Q

Describe the pathology of tissue damage caused by projectiles?

A
  • Shockwave drives tissue radially leading to a temporary cavity
  • Contamination drawn into this cavity, which collapse once the projectile has passed leaving a permanent cavity (smaller) and traps contamination in wound.
114
Q

Why are solid organs more effected than muscle/lungs etc in terms of projectile injury?

A

Not very elastic, unable to stretch, therefore tolerate cavitation poorly and causes more damage

115
Q

Describe the physics of a blast

A
  • Rapid chemical transformation of solid/liquid into a gas.
  • Under increased pressure this gas expands rapidly outward as a wave of pressure
116
Q

What is a blast wave?

A

Air at leading edge of explosion is highly compressed

117
Q

What is a primary blast injury?

A

-Only occur in high pressure explosions
- Blast wave interacts with body tissues leading to stress/shear

118
Q

What areas/organs normal affected by primary blast injury? (3)

A
  1. Tympanic membrane
  2. Lungs
  3. Bowel
119
Q

What can severe primary blasts causes?

A

Vagally mediated bradycardia/hypotension and apnoea

120
Q

What is a secondary blast injury?

A

Fragments from device or other materials energised by the blast

121
Q

With regards to secondary blast injuries what are:
1. Primary fragments
2. Secondary fragments

A
  1. From device
  2. From other materials energised by the blast
122
Q

If fragments from other victims lead to secondary blast injuries what should be advised?

123
Q

What is a tertiary blast injury?

A

Blast wave displaces objects in its path (blast wind) e.g. bodies thrown agains solid objects or structural collapse

124
Q

What is a quaternary blast injury?

A

Any other explosion related injury e.g. burn, psychological trauma

125
Q

What are the 6 types of lung injury caused by blast lung?

A
  1. Interstitial haematoma/oedema
  2. Intra-alveolar injury
  3. Pulmonary oedema (can be delayed)
  4. PTX
  5. Alveolar-venous fistula
  6. Air embolism
126
Q

What are the 3 types if injury to bowel caused by blast bowel?

A
  1. Contusion
  2. Perforation
  3. Intra-luminal bleeding
127
Q

Which type of bowel is most affected by ‘blast bowel’?

A

Large bowel

128
Q

‘Blast ear’ can cause which 3 injuries?

A
  1. TM rupture
  2. Ossicle dislocation
  3. Inner ear damage
129
Q

What are the 4 C’s in terms of an explosion?

A

Police use for their initial approach

Confirm threat
Clear people away
Cordon
Control - create Incident Control Point (ICP)

130
Q

In terms of forensics post an explosion, what should we remember to do to preserve evidence? (4)

A
  1. Only touch objects to tx patients
  2. Only move bodies to tx patients
  3. When cutting off clothes try to avoid cutting through points of penetration
  4. Take limbs with patients even if unsalvageable
131
Q

In terms of triaging post explosion, what can be a useful marker of injury and why?

A

TM rupture because blast injuries can deteriorate later

132
Q

What denotes a high mortality in a patient injured during an explosion?

A
  1. Blast lung + amputation
133
Q

Following a traumatic amputation secondary to an explosion when should we use a tourniquet?

A

Always - can no bleed initially due to vasospasm/cauterisation but will start to

134
Q

In proximal amputations following an explosion, what other injury is likely?

A

Pelvic fractures - place binder emperically

135
Q

What is the mortality in penetrating head if the patient is?
Alert
Voice
Pain
Unresponsive

A

A = 11.5%
V = 33.3%
P = 7%
U = 100%

136
Q

Describe the zones of the neck?

A
  1. Clavicle to cricoid
  2. Cricoid to angle of mandible
  3. Angle of mandible to bottom of ear
137
Q

Why were the neck zones divided as they are?

A

Zone 2 more easily explored surgical, whereas 1 and 2 more likely to need CT angiography

138
Q

What does JRCALC state about giving IV fluids in paeds burns:
1. >20%
2. 10-20%
3. <10%

A
  1. Give 10ml/kg normal saline over 1 hour
  2. If journey time >30 mins given 10ml/kg over 1 hour
  3. No fluids
139
Q

What is classed as a dangerous MOI in the NICE head injury guidelines (6)?

A

1.A fall from a height of more than 1 meter or 5 stairs
2. A high-speed RTC (pedestrian, cyclist, or vehicle occupant)
3. Roll over RTC/ ejection
4. An accident involving motorized recreational vehicles
5.Bicycle collision
6. Diving accident

140
Q

What are the borders of the ‘safety triange’ for chest drains?

A
  1. Lateral aspect pec major
  2. Nipple line
  3. Lateral aspect of latissimus dorsi
141
Q

What is the causes of life threatening chest trauma in order of how frequently they occur in TARN?

A

Flail chest ( 1 in 50 )
Tension PTX (1 in 250)
Massive HTX (1 in 1000)
Cardiac tamponade (1 in 1250)
Open PTX (1 in 10,000)

142
Q

What mechanism is most commonly associated with posterior hip dislocation?

A

Unrestrained passengers with frontal impact

143
Q

What is the effect of an:
1. engine
2. tow bar

on injuries

A
  1. Protective against frontal collisions
  2. Transmits energy directly to passenger cabin and bypasses crumped zonesW
144
Q

What is Waddells triad?

A

Injury in children hit by car whilst walking:

  • contralteral head injury
  • intrathoracic or intrabdominal injury
  • fractured femur
146
Q

In a self ventilating patient with suspected PTX/tension PTX what does FPHC recommend as:
1. First line
2. Second line
3. Third line

A
  1. Needle decompressoin 2nd IC space mid clavicular
  2. 5th IC space mid-axillary line
  3. Thoracostomy followed up by CD if level 6 practitioner
147
Q

What does the FPHC say about chest drains pre-hospital in their consensus statement

A
  • Should be avoided where possible due to:
  • prolongation of on-scene time
  • risks of kinking
  • blocking or falling out during transfers
  • long-term infection risks with non-sterile insertion techniques.

It is accepted that chest
drain insertion will be necessary in some circumstances eg high-altitude aero-medical retrieval.

148
Q

What is the complication rate of pre-hospital thorocostomy?

149
Q

What does FPHC recommend with respects to abx and thoracostomy?

A

Should be considered for pre-hospital thoracostomy, especially in cases of penetrating chest trauma, or with transport times >3 hours

150
Q

What does FPHC recommend for treatment open PTX? (2)

A
  1. Commercial chest seal, vented preferably (3 sided dressing no longer recommended)
  2. IV abx prophx
151
Q

What is the FPHC consensus statement on massive HTX? (3)

A
  1. If no respiratory compromise then drainage should be delayed until ED
  2. Where thoracostomy has shown significant haemorrage then a chest drain maybe beneficial to monitor blood loss, however should not significantly impact of scene time.
  3. Clamping chest drain for exsanguinating chest trauma, however caution needed as high chance of co-existing PTX which could tension with PPV etc.
152
Q

What is the FPHC consensus statement recommendations on flail chest?

A
  1. Where possible, sit uo
  2. Patient may find holding their ribs helps with pain
  3. Pain score and suitable analgesia
  4. No entonox a 1/3 patients with >3 rib #s have PTX as well
153
Q

What factors associated with ribs #s have been shown to lead to worse outcomes and trigger clinicians to convey to centre with CTS? (8)

A
  1. age 65 years or more
  2. three or more rib
    fractures
  3. bilateral flail chest
  4. chronic lung disease
  5. co-existent underlying lung injury
  6. anticoagulant use
  7. BMI >25
  8. oxygen saturation <90% in the Emergency Department.
154
Q

What does FPHC consensus statement say about pre-hospital pericardiocentesis?

A
  1. No evidence for its use
  2. Can cause damage
  3. Unlikely to be able to aspirate clotted blood from needle
155
Q

What are the 4 things needed for to indicate pre-hospital thoracotomy according to FPHC?

A
  1. Stab wounds to the chest or upper abdomen
  2. Cardiac arrest with loss of vital signs ≤ 15 minutes
  3. The suspected injury is suitable for temporary repair and control
  4. A chain of survival exists for definitive management following Resuscitative Thoracotomy
156
Q

How quickly does NICE suggest and RSI should be performed if needed?

A

Within 45 mins of the 999 call

157
Q

What is the time limit that NICE recommend for diverting to a TU for a trauma patient requiring an RSI as opposed to continuing onto a MTC?

A

If 60 mins or less continue to MTC, if above this divert to TU

158
Q

What does NICE state about tension PTX? (3)

A
  1. Clinical diagnosis but can used eFAST to augment this
  2. Only decompress if severe ventilatory failure of haemodynamic compromise
  3. Use thoracostomy instead of needle if expertise available
159
Q

How does NICE recommend managing open PTX?

A

Simple occlusive dressing

160
Q

When does NICE recommend decompressing a tension PTX in hospital before CXR?

A

Severe ventilatory failure of haemodynamic compromise?

161
Q

When does NICE recommend using TXA in major trauma?

A

Active or suspected bleeding ASAP but no >3 hours

162
Q

What agent does NICE recommend using in major haemorrhage in patients taking vit K antagonists?

163
Q

What target does NICE recommend for volume resusitation in major trauma patients without head injury?

A

Titrate to carotid/femoral pulse

164
Q

What does NICE recommend as first line analgesia in major trauma with:
1. IV access
2. No IVA

A
  1. Morphine
  2. IN diamorphine or ketamine
165
Q

How is CPP calculated?

166
Q

In terms of GCS, what defines
1. Mild HI
2. Moderate HI
3. Severe HI

A
  1. 13-15
  2. 9-12
  3. 8 or less
167
Q

In pre-verbal children, in terms of GCS, what score can be used instead of the verbal score

A

Grimace score

168
Q

Describe the components of an adult GCS?

A

Eye response (E)

1 -No eye opening
2- Eye opening in response to pain stimulus (a peripheral pain stimulus, such as squeezing the lunula area of the patient’s fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect)
3- Eye opening to speech (not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3)
4- Eyes opening spontaneously

Verbal response (V)

1 -No verbal response
2- Incomprehensible sounds (moaning but no words)
3- Inappropriate words (random or exclamatory articulated speech, but no conversational exchange)
4- Confused (the patient responds to questions coherently but there is some disorientation and confusion)
5- Oriented (patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month)

Motor response (M)

1- No motor response
2- Extension to pain (extensor posturing: abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3- Abnormal flexion to pain (flexor posturing: adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4- Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5- Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied)
6- Obeys commands (the patient does simple things as asked, e.g. stick out tongue or move toes)

169
Q

Describe the paediatric GCS

170
Q

Describe the grimace score?

171
Q

What does the AAGBI guidelines for transfer in HI/CVA recommend as triggers for intubation? (2)

A

1.Glasgow Coma Scale (GCS) ≤ 8
2. significantly deteriorating conscious level (GCS fall in 2 or more or motor score of 1 or more)

172
Q

What does the AAGBI guidelines for transfer in HI/CVA suggest about patients accepted for thrombectomy with regards to intubation? (2)

A

Should be transferred without delay, anterior circulation CVA rarely needs i+v

173
Q

What is the conventionally understood time target for neurosurgery with expanding heamatoma?

A

< 4 hours from injury

174
Q

What is the current indication for
1. Thrombectomy + thrombolysis
2. Thrombolysis
3. Thrombectomy only

A
  1. Acute ischaemic
    stroke with symptoms up to 4.5 h after onset
  2. Demonstrable proximal artery occlusions in
    the anterior circulation who can be treated within 24 h of
    symptom onset
  3. If i.v. thrombolysis is contraindicated (e.g. in a warfarin-treated patient with
    therapeutic anticoagulation) mechanical thrombectomy is
    recommended as the first line of treatment
175
Q

What does the AAGBI guidelines for transfer in HI/CVA recommend as essential equipment? (6)

A
  1. Portable ventilator with airway pressure/ MV and disconnect alarm
  2. Oxygen - minimum reserve of 1 hour or twice the journey times, whichever is longer
  3. Portable, battery powered monitor
  4. Adequate drugs
  5. Communication equipment

6.Other equipment; glucometer (if receiving insulin),
battery-powered syringe pumps, battery-powered i.v.
volumetric pumps, appropriate intubation equipment,
self-inflating bag, valve and mask, venous access
equipment, chest drain or equipment for finger
thoracostomy (if major trauma), DC defibrillator,
insulating blanket, torch (to assess pupils), a means to
record physiological variables and the administration of
drugs/fluids during the transfer

176
Q

What does the AAGBI guidelines for transfer in HI/CVA recommend as essential drugs? (9)

A
  1. Hypnotics e.g propofol
  2. Paralytic
  3. Opioid analgesics,
  4. Anticonvulsants
  5. Mannitol 20% or hypertonic saline
  6. Vaso-active drugs
  7. Resuscitation drugs (as in hospital resuscitation boxes)
  8. Intravenous fluids
  9. Cross-matched blood (e.g. in trauma patients)
177
Q

What does the AAGBI guidelines for transfer in HI/CVA recommend as essential monitoring? (4)

A
  1. GCS
  2. Pupils
  3. IBP (but don’t delay time critical tranfer if NIBP ok)
  4. Capnopgraphy
  5. UO (catheter)
178
Q

What does the AAGBI guidelines for transfer in HI/CVA recommend for RSI induction agent in traumatic HI?

A

Ketamine + fentanylW

179
Q

What cardiovascular physiological parameters does the AAGBI guidelines for HI/CVA suggest for
1. TBI
2. Haemorrhagic stroke/ IC bleed
3. Acute ischaemic CVA
4. Spontaneous SAH

A
  1. SBP >110 and < 150, MAP >90
  2. SBP <150 if within 6h symptoms and immediate surgery not planned
  3. SBP >140 and < 185 (if had thrombolysis/is candidate) or <220 (if not for thrombolysis)
  4. SBP >110 and <160
180
Q

What does the AAGBI guidelines for HI/CVA suggest for:
1. PaC02
2. Oyxgenation

A
  1. 4.5-5.0 (if uncal herniation imminent brief period of 4 - 4.5 can be used)
  2. 13 or above / SATS 95% or above
181
Q

What does AAGBI recommend should be checked before transfer of HI/CVA patient in terms of venitlation?

182
Q

During transfer for HI/CVA patients what does AAGBI recommend in terms of:
1. Head position
2. PEEP
3. Fluid
4. Sedation

A
  1. 20-30 degrees head up
  2. Mimimum of 5 to prevent atelectasis, up to 10 not shown to raise ICP
  3. Normal saline (isotonic)
  4. If RSI not used propofol be careful with infusion/BP
183
Q

What specific indications does the AAGBI mention are appropriate for emergency transfer by the local team? (6)

A
  1. Extradural haematoma;
  2. Acute subdural haematoma with mass effect;
  3. Obstructive hydrocephalus
  4. Acute ischaemic stroke requiring urgent thrombolysis
  5. Subarachnoid haemorrhage;
  6. Malignant middle cerebral artery infarction
184
Q

What MAP does AAGBI recommend in TBI/CVA in paeds?

A

< 3 months = 40–60
3 month-1 year = 45–75
1–5 years = 50–90
6–11 years = 60–90
12–14 years = 65–95

185
Q

What does AAGBI recommend considering in intubation children with TBI?

A

Bolus of hypertonic
saline to avoid an associated rise in ICP during predictable PCO2 rise while performing
laryngoscopy (i.e. apnoea), and to prevent the potential
associated fall in BP

186
Q

What does AAGBI mention as specifc considerations with respects to paeds transfer with brain injury?

A
  1. More prone to hypoglycaemia
  2. Accel/decel will have more affect - discuss with crew before leaving
  3. Less space around brain so small amounts of increased ICP will have big affect
  4. Do not tape eyes shut to allow frequent pupil check but care re: eye hydration
  5. If possible bring parents to allow consent at other end
187
Q

What does AAGBI suggest for audit parameters in terms of HI/CVA transfer? (10)

A
  1. Clinician accompanying patient is suitably trained in
    transfers
  2. Patient’s trachea intubated if GCS ≤ 8 before departure
  3. If intubated, capnography used during the transfer and
    all values 4–5 kPa
  4. Arterial blood gas measurement performed before
    departure
  5. Blood sugar 6–10 mmol.l1
  6. MAP ≥ 90 mmHg at all times in patients with isolated TBI
  7. Sedation, if used, administered by continuous i.v.infusion
    8.Pupillary size and reaction during transfer recorded
  8. Written record of vital sign observations
  9. Time from acceptance by receiving unit to departure
    from sending unit
188
Q

What are the BP targets to secondary transfer set by NICE in TBI

189
Q

What does JRCALC recommend in terms of BP targets in TBI? (3)

A
  1. MAP >90
  2. SBP >120
  3. Fluids if absent carotid pulse
190
Q

What does NICE reccomend in TBI for:
1. TXA (paeds and adults)
2. Hypertonic
3. When to give a pre-alert

A
  1. 2 g adul/ 30mg/kg paeds IV for moderate/severe TBI (GCS 12 or less) within 2 hours of injury
  2. 3ml/kg 5% saline
  3. GCS 8 or less
191
Q

What are the recommend doses of mannitol and hypertonic and which one has the strongest evidence?

A

3ml/kg hypertonic

0.5-1g/kg mannitol

No evidence for one over the other

192
Q

What is the quickest/most efficent way to measure burns and recommended by FPHC?

A

Threshold method

193
Q

What long protection measures should be used in traumatic lung injury? (3)

A
  1. TV 4-6ml/kg
  2. Plateau pressure of <30cmH20
  3. Use of PEEP to increase FRC
194
Q

What landmarks demarcate zone 1 neck and what structures are there? (8)

A

Clavicles/sternum to cricoid

  1. Proximal common carotid artery
  2. Subclavian arterties
  3. Vertebral arterties
  4. Lung apices
  5. Trachea
  6. Thyroid
  7. Oesophagus
  8. Spinal cord
195
Q

What landmarks demarcate zone 2 neck and what structures are there? (6)

A

Cricoid to angle of mandible

  1. Carotid and vertebral arteries
  2. Jugular veins
  3. Pharynx and larynx
  4. Trachea
  5. Oesophagus
  6. Vagus and recurrent laryngeal nerves
196
Q

What landmarks demarcate zone 3 neck and what structures are there? (6)

A

Angle of mandible to base of skull

  1. Distal carotid arteries
  2. Vertebral arteries
  3. Jugular veins
  4. Salivary and parotid glands
  5. CN IX-XII
  6. Spinal cordI
197
Q

In what type of injury and patient demographic is fat embolism more common?

A

Pelvic or long bone fractures

Young men

198
Q

When does Fat Embolism Syndrome (FES) normally present?

A

24-72 hours post injury

(acute normally leads to cardiac arrest)

199
Q

What is the triad of symptoms for Fat Embolism Syndrome (FES)

A
  1. Respiratory distress
  2. Neurological dysfunction
  3. Petechial rash
200
Q

What artery normally causes massive maxfax bleeding?

A

Ethmoidal artery which is a branch of the internal carotid artery

201
Q

Describe max fax packaging in terms of which part splints what anatomy

A
  1. Maxilla - Epistat
  2. Hard palate - bite blocks
  3. Mandible - cervical collar
202
Q

What is the most common cardiac injury caused by blunt trauma?

A

Cardiac contusion

203
Q

How is shock index calculated?

204
Q

What value of shock index (SI) is predictive of high morbidity and need for MHP?

205
Q

What nerves are likely to be damaged in a posterior hip dislocation and what neurology will it lead to?

A

Sciatic most likely, then common peroneal (once sciatic nerve branches into tibial + common peroneal at popiteal fossa)

Sciatic nerve - knee flexion/hip adduction and movement ankle/foot

Common peroneal - weakness dorsiflexion, great toe extension

206
Q

What is the definition of traumatic asphyxia?

A

Mechanical hypoxia caused by blunt compression of chest, in conjunction with inspiration against a closed glottis (Valsalva)

207
Q

How does traumatic asphyxia lead to rupture of venules in face/conjunctiva?

A

Changes in pressure in thoracic cavity cause compression of right atrium

208
Q

Why should metaraminol not be used in neurogenic shock and what can be used instead?

A

Can cause reflex bradycardia

Use ephidrine or adrenaline as both are alpha and beta agonists

210
Q

What are the indications for pre-hospital amputation (4) and what is strongly advised beforehand?

A
  1. Immediate risk to patients life due to scene safety
  2. Patient deteriorating and physically trapped by their limb and most likely will die during the time it takes to extricate
  3. Mutilated non-survivable limb with minimal soft tissue attachment causing a delay to extrication that is not life threatening
  4. A patient is dead but heir entrapment is blocking access to potentially live casualties

Call with senior clinician on call (or another consultant)

211
Q

What are the recommended antibiotics for animal/human bites according to the NICE guidelines:
1. first line
2. Pencillin alllergy oral
3. Penicillin allergy IV

A
  1. Co-amoxiclav
  2. Doxy and metronidazole
  3. Cefuroxime and metronidazole
212
Q

What do the NICE guidelines recommend in terms of abx for human bites that:
- haven’t broken skin
- have broken skin but not bleeding
- broken skin and bleeding

A
  1. No abx
  2. Conisder abx if high risk patient or area*
  3. Give abx
  • High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation

People at high risk include co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease)

213
Q

What do the NICE guidelines recommend in terms of abx for dog bites that:
- haven’t broken skin
- have broken skin but not bleeding
- broken skin and bleeding

A
  1. No abx
  2. No abx
  3. Offer antibiotics if it has
    caused considerable, deep
    tissue damage or is visibly
    contaminated (for example,
    with dirt or a tooth)
    Consider antibiotics if it is in
    a high-risk area or person at
    high risk
  • High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation

People at high risk include co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease)

214
Q

What do the NICE guidelines recommend in terms of abx for cat bites that:
- haven’t broken skin
- have broken skin but not bleeding
- broken skin and bleeding

A
  1. No abx
  2. Consider if could be deep
  3. Offer abx
215
Q

What are the key BOAST guidelines for pelvic injuries? (5)

A
  1. Pelvic injuries with CV instability should have a binder applied, go to an MTC and have TXA ASAP or within 1 hour
  2. Active bleeding pelvic injuries not responding to resusitation should undergo surgical packing (with binder in situ during surgery) or embolisation
  3. Patients undergoing damage control laparotomy from blunt injuries should have pelvic imaging (XR or CT) before theatre
  4. Pelvic binder should be removed within 24 hours of injury
  5. Reconstruction of pelvic ring should occur within 72 hours of injury
216
Q

What are the key recommendations from BOA with regards to open fractures? (5)

A
  1. IV abx with 1 hour
  2. Only remove gross contaminant
  3. Highly contaminated wound will need immediate surgical intervention
  4. High energy open fractures should have surgery within 12 hours of injury
  5. Low energy open fractures should have surgery within 24 hours of injury
217
Q

What abx should be given for open fractures and how quickly according to BOA in:
- first line
- penicillin allergy
- anaphx to penicillin

A
  1. Co-amox
  2. Cephalosporin
  3. Gentamicin

All within 1 hour of injury

218
Q

What 3 bit of kit are needed to perform FONA?

A
  1. Size 10 scalpel
  2. Bougie
  3. 6mm cuffed ETT
219
Q

What are the 4’Es mentioned in the ERC guidance about thoractomy?

A
  1. Elapsed time <10 mins?
  2. Expertise present?
  3. Equipment available?
  4. Enviroment optimised?
220
Q

At what voltage should internal defib pads be used in VF post thoracotomy?

A

10J increased to 20J if needed

221
Q

How can primary blast waves lead to vagal mediated shock?

A

Waves trigger C-fibre pulmonary baroreceptors leading to vagal stimulation

222
Q

What is the ‘critical phase of impact brain apnoea?’1

A

First 10 mins:
2 phases - apnoea and catacholamine surge

223
Q

What can the catecholamine surge lead to systemically? (6)

A
  1. Hyperglycaemia
  2. HTN
  3. Raised ICP
  4. Vasoconstriction in other vascular beds leading to ischaemic gastric mucosal ulceration +
  5. Neurogenic pulmonary oedema
  6. Myocardial necrosis
224
Q

What is traumatic mydriasis, what are the signs, and how is it caused?

A

Pupillary dilatation following blunt eye trauma due to injury of the iris sphincter muscles. It will be poorly reactive to both direct and consensual light reflex

225
Q

What should be ensured following an explosion if someone if pregnant and why?

A
  1. anti-D immunoglobulin if Rhesus negative within 27 hours as blast waves cause microscopic damage and cellular interface leading to foetal cells entering maternal bloodstream

US to rule out uterine rupture/placental abruption

226
Q

Re TXA what is the recommendations from:
1. CRASH-2
2. CRASH-3
3. NICE

A
  1. Give < 3 hours and not after (evidence of increased mortality >8 hours)
  2. Reduced mortalitiy in mild/mod isolated head injuries < 3hours. Earlier better. No improvement in severe HI
  3. 2g IV or 30mg/kg paeds in HI with GCS 12 or less if within 2 hours injury.
227
Q

What are the c/i to adenosine? (7)

A
  1. Asthma
  2. COPD
  3. Decompensated heart failure
  4. Long QT syndrome
  5. Second or third degree HB
  6. Sick sinus syndrome without PPM
  7. Severe hypotension
228
Q

How quickly following injury can crush syndrome develop?

229
Q

What does the FPHC receommend for the fluid management of crush injuries?

A

2L warmed crystalloid (not Hartmanns) prior to extrication if possible followed by 1.5L/hr following this

230
Q

What is the FPHC definition of
1. Crush injury
2. Crush syndrome

A

A crush injury is a direct injury resulting from crush.

Crush syndrome is the systemic manifestation of
muscle cell damage resulting from pressure or crushing

231
Q

Shock in crush is multifactoral, what are 3 contributing factors?

A
  1. Blood loss from injuries
  2. Shift of fluid out of IV compartment
  3. Acidosis/low Ca2+/high K+ lead to negative ionotropy
232
Q

Aside from hyperkalaemia, what is the other common electrolyte imbalance in crush syndrome?

A

Hypocalcaemia

233
Q

What role does the FPHC suggest using mannitol for in crush injury?

A

Diuresis - more in the hospital phase to augment alkaline diuresis

Some evidence it may help avoid fasciotomy in compartment syndrome

234
Q

Following a blast injury with open wounds and suspected human contamination what vaccinations should patients have? (2)

A
  1. Accelerated Hep B
  2. Tetanus
235
Q

What is:
1. Simple impalement
2. Complex impalement

A
  1. Impaled by simple object e.g knife and does not interfere with managemend
  2. Patient trapped by impaling object
236
Q

What is the Mangled Extremity Severity Score (MESS)

A

Scoring system to predict whether limb likely to be salvageable:

Uses:
1. Type of injury
2. Degree of shock
3. Level of ischaemia
4. Age

7 or more likely to need amputation

237
Q

What are the pros/cons for the following amputation devices?
1. Homatro device (‘jaws of life’)
2. Reciprocating saw

A
  1. Pros: Can be used underwater
    Cons: only can be used by FRS (but medical team likely to need to cut down to soft tissue), causes most tissue damage
  2. Pro: quickest, can be direct to skin
    Cons: Risk to rescuer, blood spatter, aerolisation of tissue, potential battery failure and cutting through surface under the limb
    Cons:
238
Q

What is suspension syndrome and what is current understanding of its mechanism?

A

Multifactoral circulatory collapse during passive hanging on a rope or in a vertical harness.

Thought to be due neurocardiogenic mechanism.

239
Q

What is the end result of suspension syndrome and give 4 reversible causes?

A

Cardiac arrest:

  1. Hyperkalaemia
  2. Hypoxia
  3. Hypothermia
  4. PE
240
Q

What are the features of acute suspension syndrome? (4)

A
  1. Near suspension syncope
    (dizziness/confusion/nausea/blurred vision/bradycardia)
  2. Suspension syncope
  3. Suspension cardiac arrest
  4. Post suspension cardiac arrest within 60mins of rescue
241
Q

What are the features of subacute suspesion syndrome? (3)

A
  1. Sensory or motor deficit in lower limbs persisting > 24 hours of rescue
  2. End organ dysfunction, particularly rhabo and AKI
  3. Delayed cardiac arrest > 60mins from rescue
242
Q

Following inhalational burns injury what lung protective ventilatory measures may be needed?

A
  1. TV 6ml/kg
  2. PEEP + plateau pressure <30cmh20
  3. Prolonged I:E ratio and low RR if risk of air trapping
  4. Nebulised heparin and NAC have been shown to be beneficial
243
Q

What is the predominant and most likely fatal aspect of primary blast injury?

A

Primary blast lung injury

244
Q

What is the definition of primary blast lung injury?

A

Radiological and clinical evidence of acute lung injury
occurring within 12 hours of exposure and not due to
secondary or tertiary injury

245
Q

What 2 factors dictate the severity of primary blast lung injury?

A

Proximity to blast

Wether or not in enclosed space - far worse if you are

246
Q

In primary blast lung injury what factor makes it unlikely patient will need I+V

A

Delayed to symptoms >2 hours

> 6 hours likely to lead to clinically important disease

247
Q

In penetrating blast injuries what abx prophx should be used for:
1. Penetrating CNS
2. Penetrating eye
3. All others

A
  1. Cef + met
  2. Ciprofloxacin
  3. Co-amox (If GI add fluconazole if perforation)
248
Q

Following bomb blast and suspected contantimation of human remains what is the PHE advice for BBV PEP?

A
  1. Take and store blood and check for seroconversion at 3 + 6 months
  2. Hep B - accelerated vaccine schedule to start < 72 hours
  3. Hep C and HIV PEP not routine recommended (HIV partly due to s/e of PEP and low risk)

FIMC (17 decks)

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